Nursing Elites

1. A newborn's mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive?

• A. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months
• B. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen
• C. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth
• D. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days

Correct answer: C

Rationale: In the scenario where a newborn's mother is positive for hepatitis B surface antigen, the infant should receive both hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. This is crucial to provide passive and active immunity against the Hepatitis B virus. Hepatitis B immune globulin provides immediate protection by giving passive immunity, while the vaccine stimulates active immunity in the infant. Administering both within 12 hours of birth is important to prevent vertical transmission of the virus.

2. A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

• A. A client who is at 38 weeks of gestation and reports a cough and fever
• B. A client who has missed a period and reports vaginal spotting
• C. A client who is at 14 weeks of gestation and reports nausea and vomiting
• D. A client who is at 28 weeks of gestation and reports of painless vaginal bleeding

Correct answer: D

Rationale:

3. During the admission assessment of a client at 38 weeks of gestation with severe preeclampsia, what would the nurse expect as a finding?

• A. Tachycardia
• B. Absence of clonus
• C. Polyuria
• D. Report of headache

Correct answer: D

Rationale: Severe preeclampsia is characterized by hypertension and proteinuria after 20 weeks of gestation. Headache is a common symptom in clients with severe preeclampsia due to cerebral edema or vasospasm. Tachycardia (Choice A) is not typically associated with severe preeclampsia. Clonus (Choice B) is a sign of hyperactive reflexes, often seen in clients with severe preeclampsia. Polyuria (Choice C) is not a typical finding in clients with severe preeclampsia.

4. A woman at 38 weeks of gestation and in early labor with ruptured membranes has an oral temperature of 38.9�C (102�F). Besides notifying the provider, which of the following is an appropriate nursing action?

• A. Recheck the client's temperature in 4 hours
• B. Administer glucocorticoids intramuscularly
• C. Assess the odor of the amniotic fluid
• D. Prepare the client for emergency cesarean section

Correct answer: C

Rationale: In a pregnant woman with a temperature of 38.9�C (102�F) in early labor with ruptured membranes, assessing the odor of the amniotic fluid is crucial. Foul-smelling or malodorous amniotic fluid could indicate infection, such as chorioamnionitis, which poses risks to both the woman and the fetus. This assessment can help in determining if an infection is present and prompt appropriate interventions. Rechecking the temperature, administering glucocorticoids, or preparing for an emergency cesarean section are not the most immediate or appropriate actions in this scenario.

5. A client with acute respiratory failure (ARF) may present with which of the following manifestations? (Select one that doesn't apply.)

• A. Severe dyspnea
• B. Decreased level of consciousness
• C. Headache
• D. Nausea

Correct answer: D

Rationale: In acute respiratory failure (ARF), the body is not getting enough oxygen, leading to respiratory distress. Symptoms of ARF typically include severe dyspnea (difficulty breathing), decreased level of consciousness due to hypoxia, and headache from inadequate oxygenation to the brain. Nausea is not a typical manifestation of ARF and would not be expected in this condition.

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